Interventional Pain Procedures: A Narrative Review Focusing on Safety and Complications. Part 4 — Peripheral Nerve, Joint, Musculoskeletal, and Regenerative Interventions

Giuliano Lo Bianco,1 Ezio Amorizzo,2 Felice Occhigrossi,3 Marco Mercieri,4 Sudhir Diwan,5 Miles Day,6 Maurizio Marchesini,7 Emanuele Piraccini,8 Annu H Navani,9,10 Douglas P Beall,11 Philippe Mavrocordatos,12 Ali Valimahomed,13 Timothy R Deer,14 Alaa Abd-Elsayed151Anesthesiology and Pain Department, Fondazione Istituto G. Giglio, Cefalù, Italy; 2Department of Anesthesiology, San Paolo Hospital, Civitavecchia, Italy; 3Pain Therapy Unit, San Giovanni-Addolorata Hospital, Rome, Italy; 4Department of Medical and Surgical Sciences and Translational Medicine, Sapienza University of Rome, Rome, Italy; 5Manhattan Spine and Pain Medicine, New York, NY, USA; 6Department of Anesthesiology, Texas Tech University Health Sciences Center, Lubbock, TX, USA; 7Anesthesiology and Pain Department, Mater Olbia Hospital, Olbia, Italy; 8Unit of Pain Medicine, AUSL Bologna, Bologna, Italy; 9Le Reve Regenerative Wellness, San Jose, CA, USA; 10Boomerang Health Care, Walnut Creek, CA, USA; 11Comprehensive Specialty Care, Edmond, OK, USA; 12Swiss Pain Institute, Lausanne, Switzerland; 13Interventional Pain Medicine, Advanced Orthopedics Sports Medicine Institute, Freehold, NJ, USA; 14Department of Anesthesiology, West Virginia University, Morgantown, WV, USA; 15Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USACorrespondence: Giuliano Lo Bianco, Email giulianolobianco@gmail.comAbstract: The first three installments of this series examined the safety and complications of injections for spinal pain (Part 1), interventional procedures for back pain (Part 2), and sympathetic and ganglion-targeted techniques (Part 3). This fourth and concluding article addresses the interventions performed away from the neuraxis and the sympathetic chain, which together account for much of everyday pain practice: peripheral and cranial nerve procedures (blocks, chemical neurolysis, radiofrequency, cryoneurolysis, and peripheral or occipital nerve stimulation); joint, bursal, and tendon injections; regenerative or orthobiologic injections; chemodenervation with botulinum toxin; sacroiliac and musculoskeletal soft-tissue procedures; interventions for painful neuroma; and percutaneous ablation of painful bone metastases. Each family carries a characteristic and occasionally serious spectrum of adverse events: local-anesthetic systemic toxicity, pneumothorax, and nerve injury with peripheral and truncal blocks; post-procedural neuritis, thermal injury, and neuroma with radiofrequency and cryoneurolysis; device-related events with peripheral and occipital stimulation; septic arthritis, chondrotoxicity, and the recently recognized structural joint effects of intra-articular corticosteroids; standardization and regulatory concerns with orthobiologics; local weakness, dysphagia, and toxin spread with botulinum toxin; thermal or cryo injury to adjacent structures and pathological fracture with percutaneous ablation of bone metastases; and largely transient events after sacroiliac joint and musculoskeletal soft-tissue procedures. We also address a category common to almost all of these procedures but seldom reviewed: the complications specific to ultrasound guidance itself, chiefly infection from contaminated gel or transducers and the pitfalls of needle-tip visualization. Because most of these targets are superficial and amenable to ultrasound guidance, the reported safety profile is generally favorable; however, this synthesis is narrative and qualitative, and much of the underlying evidence derives from case reports, small series, and heterogeneous cohorts, so a low reported complication burden should not be equated with a precisely established low incidence. As throughout the series, appropriate patient selection, real-time image guidance, aseptic technique, dose and volume limitation, and attention to antithrombotic status are the recurring determinants of safety.Keywords: interventional pain procedures, peripheral nerve block, radiofrequency, orthobiologics, botulinum toxin, ultrasound guidance, complications, safety